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The outbreak of COVID-19 has overwhelmed healthcare systems all over the world. The aim of this article is to describe the process of transforming the Vall d'Hebron University Hospital, the second largest hospital in Spain, into a COVID-19 centre coordinating response to the pandemic in its reference area.The study draws on the experience of the authors in transforming the hospital into a comprehensive resource in response to the COVID-19 pandemic. The strategy is based on four central strategies: early planning, coordination of all healthcare agents in its reference area, definition of clear leadership roles, and the organisation of care based on multidisciplinary teams with minimal recruitment of new staff.The transformation strategy enabled the hospital to cope with the surge in patients without exceeding its capacity. During the response phases, which amounted to a period of 57 days, 3106 patients consulted the ER and 2054 were admitted, 346 of whom were treated at the ICU. To accommodate the number of adult COVID-19 patients, adult ICU availability was progressive increased by 371%, and ordinary beds increased by 240. A total of 671 staff members went on sick leave after testing positive for COVID-19.The transformation experience of the hospital provides insight into how effectively adapt the structures and functioning of large hospitals. The relevance of territorial coordination during the pandemic is stressed as an effective strategy that contributed coping the pandemic.

Resumen Los márgenes multifuncionales (MMF) son franjas de vegetación espontánea o sembrada que se implantan en parcelas agrícolas desempeñando múltiples funciones. Establecerlos en cultivos herbáceos de secano es una práctica innovadora y fuente de múltiples beneficios medioambientales y agronómicos. Los márgenes sirven de refugio de fauna silvestre, favorecen la presencia de polinizadores e insectos auxiliares y representan una barrera física para la escorrentía y la deriva de productos fitosanitarios. Una vez que los márgenes son segados, los restos orgánicos se degradan por la biota del suelo, provocando una recirculación de nutrientes y el incremento de materia orgánica. En este trabajo se estudió el efecto de los MMF sobre la biodiversidad de la fauna epigea y el secuestro de carbono en el suelo. Se compararon tres tipos de márgenes: dos mezclas diferentes de semillas sembradas y la flora espontánea como márgen testigo; asimismo se midió el cultivo adyacente. Los márgenes promovieron una mayor biodiversidad de artrópodos que el propio cultivo, especialmente coleópteros. El analisis de suelo mostró pérdida de carbono en el cultivo, manejado de forma tradicional, aumentando en todos los tipos de MMF, tanto sembrados como espontáneos. Esta práctica tiene un gran potencial de implantación en cualquier tipo de cultivo extensivo.

In recent decades, physical techniques based on the application of magnetic fields (MF) have been developed in the agricultural sector with favorable results in plant germination and growth. The main objective of this study is to determine the effects of magnetic treatment on the germination of seeds of the following species Salvia officinalis L. and Calendula officinalis L. Groups of seeds were exposed to MF of 125 mT for different times, other groups of seeds were subjected to magnetic pretreatment and others were used as control. Germination tests were performed under laboratory conditions. The parameters were: germination time of the first seed (T1), time for reaching 10 -75% of germination (T10, T25, T50 and T75), mean germination time (MGT) and number of germinated seeds (Gmax), provided by Seedcalculator software. The parameters recorded for both seeds with treatment and pretreatment were lower than the value of the corresponding control, chronic exposure at 125 mT provided the highest results; MGT was significantly reduced compared to controls. (T1-T50) were also significantly reduced.

Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures. We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)—Top–down technique; (4) transversus abdominis release (TAR)—bottom–up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains. Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.

Objective:To identify factors that increase the microbial load in the operating room (OR) and recommend solutions to minimize the effect of these factors.Design:Observation and sampling study.Setting:Academic health center, public hospitals.Methods:We analyzed 4 videotaped orthopedic surgeries (15 hours in total) for door openings and staff movement. The data were translated into a script denoting a representative frequency and location of movements for each OR team member. These activities were then simulated for 30 minutes per trial in a functional operating room by the researchers re-enacting OR staff-member roles, while collecting bacteria and fungi using settle plates. To test the hypotheses on the influence of activity on microbial load, an experimental design was created in which each factor was tested at higher (and lower) than normal activity settings for a 30-minute period. These trials were conducted in 2 phases.Results:The frequency of door opening did not independently affect the microbial load in the OR. However, a longer duration and greater width of door opening led to increased microbial load in the OR. Increased staff movement also increased the microbial load. There was a significantly higher microbial load on the floor than at waist level.Conclusions:Movement of staff and the duration and width of door opening definitely affects the OR microbial load. However, further investigation is needed to determine how the number of staff affects the microbial load and how to reduce the microbial load at the surgical table.

Background Increased recognition of the dangers of opioid analgesia has led to significant focus on strategies for reducing use through multimodal analgesia, enhanced recovery protocols, and standardized guidelines for prescribing. Our institution implemented a standard protocol for prescribing analgesics at discharge after ventral hernia repair (VHR). We hypothesize that this strategy significantly reduces opioid use. Methods A standardized protocol for discharge prescribing was implemented in March 2018. Patients were prescribed ibuprofen, acetaminophen, and opioids based on milligram morphine equivalent (MME) use the 24 hours prior to discharge. We retrospectively reviewed prescriptions of opioids for two 6-month periods—July-December 2017 (PRE) and July-December 2018 (POST)—for comparison using EPIC report and the South Carolina Prescription Monitoring Program. Analysis performed included Mann-Kendall linear trend test and Student’s t-test for continuous variables. Results VHR was performed in 105 patients in the PRE and 75 patients in the POST group. Total MME prescribed decreased significantly from mean 322.7 + 261.3/median 225 (IQR 150-400) MME to 141.6 + 150.4/median 100 (50-184) MME ( P < .001). This represents a 57% reduction in mean opioid MME prescriptions. Acetaminophen prescribing increased from 10% to 65%, and ibuprofen from 7.6% to 61.3%. Refills were prescribed in 21 patients (20%) during the PRE period, which decreased to 10.7% during the POST group ( P = .141). Implementation of an evidence-based protocol significantly reduces opioid prescribing after VHR. Discussion A multimodal approach to postoperative pain management decreases the need for opioids. The additional implementation of an evidence-based prescribing protocol results in significant reduction of opioid use following VHR.

Primary thoracoabdominal hernias involve the triad of an intercostal hernia, abdominal wall hernia, and diaphragmatic hernia. We report a case series of this rare entity and describe the evolution and outcomes. We completed a retrospective analysis of thoracoabdominal hernia repairs performed January 2010–April 2019 at Prisma Health–Upstate and Carolinas Medical Center. This includes all patients with spontaneous defects, excluding incisional hernias or those resulting from external trauma. Of 16 patients with thoracoabdominal hernias, 15 patients developed hernias after forceful coughing and one patient developed a hernia after strenuous physical activity. Seven patients required at least one additional intervention; two for recurrence; two for recurrence of original intercostal repairs done elsewhere; two for wound complications; and one had a missed abdominal wall component. Primary thoracoabdominal hernias require a high index of suspicion. Durable repair involves complex reconstruction of the thoracoabdominal wall including the diaphragm, intercostal space, rib fracture fixation, and mesh reinforcement of the abdominal wall with permanent fixation constructs.

Parastomal hernias (PSH) are the most common complication of stoma creation and can cause significant morbidity. We present a consecutive series of patients receiving prophylactic mesh augmentation (PMA) for prevention of PSH. This retrospective review evaluates the efficacy and outcomes of PMA for PSH prevention, and retrospectively compares traditional keyhole PMA (tPMA) (n = 28) with a prophylactic Stapled Ostomy Reinforcement with Retromuscular Mesh technique (pSTORRM) (n = 24). PMA was performed in 52 cases between January 2015 and July 2018. All cases used a large-pore, non-coated, mid-weight polypropylene mesh placed in the retrorectus space. With a median follow-up of 16 mos, parastomal hernia was confirmed in 11.5% (n = 6), 5 of whom were symptomatic. patient-reported outcomes (PRO) indicated 6 additional patients with symptoms associated with PSH without clinical or radiographic confirmation. Patients had similar comorbidities and operative characteristics between tPMA and pSTORRM techniques, and no difference in a median follow-up. pSTORRM patients had fewer surgical site infections (8.3 vs 32.1%; p = 0.046) and occurrences (12.5 vs 46.4%; p = 0.015), and lower rate of PSH, though not statistically significant (4.2 vs 17.9%; p = 0.195). Permanent synthetic mesh placed as a sublay in the retromuscular space is safe and appears to decrease the risk of PSH formation after the creation of permanent stomas. A stapled technique may provide advantages over a traditional keyhole technique.

Introduction Currently, the need for additional myofascial release (AMR) in addition to retromuscular dissection during open Rives-Stoppa hernia repair is determined intraoperatively based on the discretion of the surgeon. We developed a novel method to objectively predict the need for AMR preoperatively using computed tomography (CT)-measured rectus width to hernia width ratio (RDR). Methods A retrospective chart review of all patients who underwent open retro-muscular mesh repair of midline ventral hernia between August 1, 2007 and February 1, 2018, who had a preoperative CT scan within 1 year prior to their operation. The primary endpoint was the ability of the defect ratio to predict the need for AMR in pursuit of fascial closure. The secondary endpoint was the ability of Component Separation Index (CSI) to predict the need for AMR to obtain fascial closure. Results Of 342 patients, 208 repaired with rectus abdominis release alone (RM group), while 134 required AMR (RM + group). An RDR of > 1.34 on area under the curve analysis predicted the need for AMR with 77.6% accuracy. There was a linear decrease in the need for AMR with increasing RDR: RDR 2 in just 10.8%. Similarly, CSI > 0.146 predicted the need for AMR with 76.3% accuracy on area under the curve analysis. Conclusion The RDR is a practical and reliable tool to predict the ability to close the defect during open Rives-Stoppa ventral hernia repair without AMR. An RDR of > 2 portends fascial closure with rectus abdominis myofascial release alone in 90% of cases.

Introduction Perioperative opioid analgesia has been extensively reexamined during the opioid epidemic. Multiple studies have demonstrated over prescription of opioids, demonstrating the need for change in prescribing practices. A standard opioid prescribing protocol was implemented to evaluate opioid prescribing trends and practices. Objectives To evaluate opioid use after primary ventral, inguinal, and incisional hernia repair and to assess clinical factors that may impact opioid prescribing and consumption. Secondary outcomes include the number of refills, patients without opioid requirement, difference in opioid use based on patient characteristics and adherence to prescribing protocol. Methods This is a prospective observational study examining patients undergoing inguinal, primary ventral and incisional hernias between February and November 2019. A standardized prescribing protocol was implemented and utilized for postoperative prescribing. All data was captured in the abdominal core health quality collaborative (ACHQC) and opioid use was standardized via morphine milligram equivalents (MME). Results 389 patients underwent primary ventral, incisional, and inguinal hernia repair, with a total of 285 included in the final analysis. 170 (59.6%) of patients reported zero opioid use postoperatively. Total opioid MME prescribed and high MME consumption were significantly higher after incisional hernia repair with a greater number of refills were required. Compliance with prescribing protocol resulted in lower MME prescription, but not actual lower MME consumption. Conclusions Implementation of a standardized protocol for opioid prescribing after surgery decreases the total MME prescribed. Compliance with our protocol significantly reduced this disparity, which has the potential for decreasing abuse, misuse, and diversion of opioids by better estimating actual postoperative analgesic requirements.

Opioids are commonly prescribed beyond what is necessary to adequately manage postoperative pain, increasing the likelihood of chronic opioid use, pill diversion, and misuse. We sought to assess opioid utilization and patient-reported outcomes (PROs) in patients undergoing ventral hernia repair (VHR) following the implementation of a patient-tailored opioid prescribing guideline.A patient-tailored opioid prescribing guideline was implemented in March of 2018 for patients undergoing inpatient VHR in a large regional healthcare system. We retrospectively assessed opioid utilization and patient-reported outcomes among patients who did (n = 42) and did not receive guideline-based care (n = 121) between March 2018 and December 2019. PROs, operative details, and patient characteristics were extracted from the Abdominal Core Health Quality Collaborative (ACHQC) registry data, and length-of-stay and prescription information were extracted from the electronic health record system at the healthcare institution.The milligram morphine equivalents (MME) prescribed at discharge was lower for patients receiving guideline-based care (Median = 65, interquartile range [IQR] = 50-75) than patients receiving standard care (Median = 100, IQR = 60-150). After adjusting for patient characteristics, the odds of receiving an opioid refill after discharge did not significantly differ between patient groups (P = 0.43). Patient Reported Outcomes Measurement Information System (PROMIS) pain scores and hernia-specific quality-of-life (HerQLes) scores at follow-up also did not differ between patients receiving guideline-based care (Mean PROMIS = 57.3; Mean HerQLes = 53.1) versus those that did not (Mean PROMIS = 56.7; Mean HerQLes = 46.6).Patients who received tailored, guideline-based opioid prescriptions were discharged with lower opioid dosages and did not require more opioid refills than patients receiving standard opioid prescriptions. Additionally, we found no differences in pain or quality-of-life scores after discharge, indicating the opioids prescribed under the guideline were sufficient for patients.

To achieve the challenges raised in Agenda 2063 and the Malabo Declaration, new agricultural techniques need to be promoted. Practical approaches to implement climate smart agriculture and sustainable agriculture, able to deliver at field level, are required. These include sustainable soil and land management that allows different user groups to manage their resources, including water, crops, livestock and associated biodiversity, in ways that are best suited to the prevailing biophysical, socio-economic and climatic conditions. The adoption of locally adapted sustainable soil management practices is needed to support climate change mitigation and adaptation from the agricultural perspective. In this sense, Conservation Agriculture (CA) can be adapted to local conditions, and help achieve the key objectives. The application of CA principles brings multiple benefits, especially in terms of soil conservation, but also for mitigating climate change. In fact, CA has the ability to transform agricultural soils from being carbon emitters into carbon sinks, because of no-tillage (NT) techniques and the return to the soil of diverse crop biomass from above-ground parts of plants and from diverse roots systems and root exudates. Similarly, fossil energy use decreases due to the reduction in agricultural operations, and so less CO2 is emitted to the atmosphere. Lower greenhouse gas (GHG) emissions in CA also result, because of reduced and more efficient use of inputs. Scientific studies confirm the sequestration potential of increased soil organic carbon (SOC) stocks on croplands in Africa on each of the continent's major bioclimatic areas. Coefficients of SOC sequestration for Africa are presented in this chapter.

Introduction/Background*The impact of the COVID-19 pandemic on Spanish hospitals over the past year has forced healthcare institutions to make drastic changes in the management of oncology patients. The main objective of this study is to describe the changes in ambulatory attendance of patients with gynecological cancer and the ease of contact with the gynaecological oncology section reported by users.MethodologyThe GineonCoVID study is a multicenter Spanish study that collect data from a national survey. The anonymous survey consists of 23 questions regarding the personal experience of the patient and modifications in health care during follow up of patient with gynecological malignancies from April to May 2021. The survey has been divided into 3 sections. In this sub-analysis, questions regarding follow-up modifications and the perspective of the patients with gynecological cancer about changes were analyzed.Result(s)*376 patients responded to the survey. The median age was 58 years. 43% of the patients were diagnosed with endometrial cancer, 27.3% with ovarian cancer and 24.1% with cervical cancer. 85% of the patients had an appointment that was delayed by the pandemic. 67.7% considered that the situation justified the delay of the appointment. 93.3% who contacted the gynecological oncology unit were able to solve the problem by telephone. Upon entering the consultation, 41.3% were questioned about COVID symptoms or contacts. 97.6% considered that adequate measures were taken to avoid contagion during the medical visit. Regarding how they would value the care received (scale of 1–10), 2.2% scored it with a 7;6.7% with 8;23.2% with 9 and 67.7% with 10.Conclusion*The COVID-19 pandemic and the redistribution of health system resources have forced the development of variations in the assistance and follow-up patients with gynecological cancer in order to decrease the number of hospital visits and minimize the risk of infection. Telephone consultations and delay in routinary tests were very useful tools during this period without compromising the quality of care.

The aim of this study was to investigate the effects of thermal processing on physicochemical properties, steviol glycosides, bioactive compounds, and antioxidant capacity degradation of a beverage based on exotic fruit juices, orange juice, açaí, and oat and sweetened with Stevia rebaudiana water extracts at different concentrations. The experimental design comprised a response surface methodology according to a central composite face-centered design. The variable ranges were 60–99°C, 0.25–15 min, 0–2.5% Stevia percentage. This design was used to determine the optimal thermal processing-Stevia concentration in order to obtain the best retention of bioactive compounds and physicochemical properties in the beverage following thermal processing. Thermal processing conducted in the sample containing 2.5% Stevia at 82.4°C for 3.8 min led to the beverage with the greatest presence of antioxidant compounds. The evaluation of the thermal processing critical parameters on antioxidant compounds can contribute to achieve optimal processing conditions in order to obtain new beverages with high antioxidant potential.

OBJECTIVES In July 2016, as a result of patient demand, we introduced a rapid initiation option (RIO) to offer a first medical appointment and antiretroviral therapy (ART) initiation within 2 days of HIV diagnosis at 56 Dean Street (56DS) , a combined sexual health and HIV treatment service in London, UK. METHODS We performed a retrospective case-note review of patients newly diagnosed with HIV infection at 56DS following the introduction of the new RIO from July to October 2016. In order to assess the effect of the new service on ART uptake, we chose a comparison group of newly diagnosed patients at 56DS from 1 year earlier: July to October 2015. RESULTS In the 4 months following RIO introduction, there was a reduction in the median time from HIV diagnosis to the first medical appointment (7 versus 15 days; P

Background/Aims:This work examines the perception of the stop voicing contrast in Spanish and English along four acoustic dimensions, comparing monolingual and bilingual listeners. Our primary goals are to test the extent to which cue-weighting strategies are language-specific in monolinguals, and whether this language specificity extends to bilingual listeners.Methods:Participants categorized sounds varying in voice onset time (VOT, the primary cue to the contrast) and three secondary cues: fundamental frequency at vowel onset, first formant (F1) onset frequency, and stop closure duration. Listeners heard acoustically identical target stimuli, within language-specific carrier phrases, in English and Spanish modes.Results:While all listener groups used all cues, monolingual English listeners relied more on F1, and less on closure duration, than monolingual Spanish listeners, indicating language specificity in cue use. Early bilingual listeners used the three secondary cues similarly in English and Spanish, despite showing language-specific VOT boundaries.Conclusion:While our findings reinforce previous work demonstrating language-specific phonetic representations in bilinguals in terms of VOT boundary, they suggest that this specificity may not extend straightforwardly to cue-weighting strategies.

The effect of skin closure technique on surgical site occurrences (SSO) after open abdominal wall reconstruction (AWR) with retromuscular polypropylene mesh placement is largely unknown. We hypothesize that layered subcuticular skin closure with cyanoacrylate skin adhesive is protective of surgical site infection compared to standard stapled closure.A retrospective review utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database of all patients at Prisma Health-Upstate. All patients with open abdominal wall reconstruction (AWR) of midline incisional hernia defects with retromuscular polypropylene mesh placement from January 2013 to February 2020 were included. Patient demographics, comorbidities, type of hernia repair with mesh location, method of skin closure, and SSOs were collected. Skin closure method was divided into two groups, reflecting a temporal change in practice: staples (historical control group) versus subcuticular suture with cyanoacrylate skin adhesive with/without polymer mesh tape (study group). Primary endpoint was SSI and SSO. Secondary endpoints were SSO or SSI requiring procedural intervention (SSOPI/SSIPI). Standard statistical methods were utilized.A total of 834 patients were analyzed, with 263 treated with stapled skin closure and 571 with subcuticular and adhesive closure. On univariate analysis, the incidence of SSI was significantly lower in the study group (11.8 vs 6.8%; p = 0.002), as was the need for SSIPI (11.8 vs 6.7%; p = 0.015). Rate of SSO was not significantly different between groups (28.1 vs 27.2%), but the rate of SSO requiring intervention was lower in the study group (14.1 vs 9.3%; p = 0.045).Layered skin closure technique, including subcuticular closure and adhesive, may reduce the risk of surgical site infection after open AWR. A prospective randomized trial is planned to confirm these findings.

Myofascial release (MFR) techniques, including retromuscular hernia repair, are often considered one-time repairs. We report recurrent ventral hernia repair (RVHR) in patients with prior MFR, focusing on redo-RM repair.Retrospective analysis of all patients undergoing RVHR after prior MFR. Primary outcomes were operative time, surgical site infection (SSI), surgical site occurrence (SSO), and 20-month recurrence.111 RVHR were performed after MFR. For patients with prior external oblique release (EOR, n = 31), transversus abdominis release (TAR) was used for repair in 13. For patients with prior TAR/PCS (posterior component separation) (n = 22), EOR (n = 2) and redo-TAR (n = 3) were employed with comparable results. Prior retromuscular (RM) repair was performed in 92 patients. Redo-RM (n = 32) and intraperitoneal onlay mesh (IPOM; n = 38) were most common. Operative time was longer for redo-RM. SSI (12.5 vs 7.9%), SSO (40.1 vs 39.5%), and recurrence (18.8 vs 16.2%) were similar for redo-RM and IPOM repair.RVHR after prior MFR does not preclude additional MFR. Redo-RM VHR outcomes are similar to those repaired with other techniques.

Threads are the building blocks of solar prominences and very often show longitudinal oscillatory motions that are strongly attenuated with time. The damping mechanism responsible for the reported oscillations is not fully understood yet. To understand the oscillations and damping of prominence threads it is mandatory to investigate first the nature of the equilibrium solutions that arise under static conditions and under the presence of radiative losses, thermal conduction and background heating. This provides the basis to calculate the eigenmodes of the thread models. The nonlinear ordinary differential equations for hydrostatic and thermal equilibrium under the presence of gravity are solved using standard numerical techniques and simple analytical expressions are derived under certain approximations. The solutions to the equations represent a prominence thread, i.e., a dense and cold plasma region of a certain length that connects with the corona through a prominence corona transition region (PCTR). The solutions can also match with a chromospheric-like layer if a spatially dependent heating function localised around the footpoints is considered. We have obtained static solutions representing prominence threads and have investigated in detail the dependence of these solutions on the different parameters of the model. Among other results, we have shown that multiple condensations along a magnetic field line are possible, and that the effect of partial ionisation in the model can significantly modify the thermal balance in the thread and therefore their length. This last parameter is also shown to be comparable to that reported in the observations when the radiative losses are reduced for typical thread temperatures., Accepted for publication in A&A

Several challenges exist for referral and transport of critically ill children in resource-limited regions such as Latin America; however, little is known about factors associated with clinical outcomes. Thus, we aimed to describe the characteristics of critically ill children in Latin America transferred to pediatric intensive care units for acute respiratory failure to identify risk factors for mortality. We analyzed data from 2,692 patients admitted to 28 centers in the Pediatric Collaborative Network of Latin America Acute Respiratory Failure Registry. Among patients referred from another facility (773, 28%), nonurban transports were independently associated with mortality (adjusted odds ratio = 9.4; 95% confidence interval: 2.4–36.3).

Aquagenic keratoderma is an uncommon acquired dermatosis characterized by edema and whitish-translucent papules triggered by immersion or contact with water. Cases have been described in association with certain medications, hyperhidrosis, and cystic fibrosis. The aim of this review is to evaluate the effectiveness of different treatments for aquagenic keratoderma. We reviewed the literature and analyzed treatments for aquagenic keratoderma described in case series and reports. Aquagenic keratoderma associated with hyperhidrosis can be treated effectively. Tap water iontophoresis, endoscopic thoracic sympathectomy, botulinum toxin injections, and oxybutynin are effective against refractory forms. Topical salicylic acid and aluminum salts are effective, but of little value as maintenance therapy. Oral oxybutynin 5 mg/d is probably the best option for treating aquagenic keratoderma. The reported pathophysiological effects of nonsteroidal anti inflammatory drugs in this setting suggest that the use of prostaglandins might be justified. Additional studies are needed to investigate these hypotheses and resolve other questions.

We classify the phase portraits of the cubic systems in the plane such that they do not have finite critical points, and the critical points on the equator of the Poincaré sphere are isolated and have linear part nonidentically zero.

Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures.We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)-Top-down technique; (4) transversus abdominis release (TAR)-bottom-up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains.Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.

Background Recent data on opioid consumption indicate that patients typically require far less than is prescribed. Prisma Health Upstate Hernia Center adopted standardized postoperative prescribing after hernia repair and began tracking patient-reported opioid utilization. The aim of this study is to evaluate patient opioid use after hernia repair in order to guide future prescribing. Methods All patients who underwent primary ventral (umbilical and epigastric), incisional, and inguinal hernia repair between February and May 2019 were reviewed. Patients reported the number of opioid pills taken at their first postoperative visit and documented either in the progress note or in the Americas Hernia Society Quality Collaborative (AHSQC) patient-reported outcomes (PRO) questionnaire. All demographic, operative, and outcomes data were captured prospectively in the AHSQC. Opioid use reported as milligram morphine equivalents (MME). Results A total of 162 surgeries were performed during the study period, and 107 had patient-reported opioid use for analysis. Inguinal hernia repair was performed in 36 patients, 10 primary ventral hernia repairs, and 61 incisional hernia repairs. No opioid use was reported in 63.9% of inguinal hernias, 60% of primary ventral hernias, and 20% of incisional hernias. Inguinal hernia patients consumed a mean of 10.5 MME, primary ventral patients 11 MME, and incisional hernia patients 78.5 MME. Conclusion Patients require little to no opioid after primary ventral or inguinal hernia repair and opioid-free surgery is feasible. Incisional hernia is more heterogenous, but the majority of patients still required less opioid than previously thought.